Fillable Printable Direct Deposit Payment Authorization - Florida

Direct Deposit Payment Authorization - Florida

DFS-A1-26E rev.12/2010

STATE OF FLORIDA

DIRECT DEPOSIT PAYMENT AUTHORIZATION

State of Florida Vendor Use Only

Please complete this form and return to: Direct Deposit Section

Department of Financial Services

200 East Gaines Street

Tallahassee, Florida 32399-0359

PAYEE INFORMATION

Name: Federal Tax ID Number: -

Address:

OR Social Security Number *:

- -

Direct Deposit Action Requested: (Please check one)

Start Change

The social security number is required to be collected pursuant to 26 USC 6109, and will only be used for the purpose of complying

with filing requirements imposed by the Internal Revenue Code and to comply with Section 119.071(5)(a)7, F.S.

PAYEE CONTACT INFORMATION

Name: Telephone Number: ( ) Ext:

E-Mail Address: Fax Number: ( )

NOTE: ALL SIGNATURES MUST BE ORIGINAL. NO COPIES OR FAXES WILL BE ACCEPTED.

AUTHORIZATION:

I hereby authorize Direct Deposit Section to verify with the Financial Institution the accuracy of the account information provided. I

hereby authorize the State of Florida to initiate credit entries and, if necessary, a debit entry in order to reverse a credit entry made in

error, in accordance with NACHA rules (Article II, Sections 2.4 and 2.5.) I hereby authorize these payment instructions, and accept the

terms and conditions for Electronic Funds Transfer payments on the reverse side of this form.

Authorized Signature: Title:

Printed Name: Date:

FINANCIAL INSTITUTION INFORMATION:

Financial Institution Name: Telephone:( )

Address: Account Name:

Account Type: Checking Savings

ACCOUNT INFORMATION:

Transit Routing Number of Your Financial Institution: Your Account Number (Start at the left, leave unused spaces blank):

IAT

Please check this box if your funds are deposited in a U.S. financial institution and the entire amount is subsequently forwarded

to a financial institution in a foreign country. See the instructions page on the reverse side of this form for further explanation

on IAT (International ACH Transactions).

FINANCIAL INSTITUTION VERIFICATION - (MUST BE COMPLETED BY YOUR FINANCIAL INSTITUTION BEFORE SUBMITTING)

I have verified that the account and transit-routing numbers provided above are correct. I have further verified that the person signing

as the payee is an authorized signer on the account specified above.

Print Name: Title of Bank Officer:

Signature of Bank Officer:Date:

Bank Officer Telephone Number: ( )Ext:

For Florida Department of Financial Services Use Only:

DM: COMP: FC: VVC:

VMP: VV: VB: APPR:

Comments:

DFS-A1-26E rev.12/2010

DFS-A1-26E

INSTRUCTIONS

This formis for Vendors doing business with the State of Florida, NOT for Employees or Florida Retirement System Retirees.

Only forms with original signatures will be accepted.

Processing time is approximately 4 to 6 weeks following receipt of the completed form. Please complete all information requested on

this form. If there is a change in account information (such as change to the account name, bank account number or transit-routing

number) please check “Change” in the appropriate box in the “Payee Information” Section under “Direct Deposit Action Requested.”

The accuracy of the information provided in the Financial Institution Information section is very important. This form requires

account and transit-routing information to be verified by your financial institution. Providing account information does not authorize

the State of Florida to access account activity on your account.

The name on the Direct Deposit Payment Authorization Form must match the Payee name on file with the State of Florida Vendor

payment system for payments to be sent electronically. If you are currently receiving payments via State warrant, you should use the

first line of Payee exactly as it appears on the State of Florida warrant. It is important to note that this authorization applies to all

payments to your organization from the State of Florida. Please take this into consideration when initiating direct deposit. In addition,

the State cannot send different payments to different accounts at this time. All payments from the State of Florida will be sent to the

single account you designate.

under the “Vendors” section. All payments are

shown, not just those made by direct deposit. If you want to know when a payment will be processed or the details on a received

payment, please contact the state agency issuing your payments.

INTERNATIONAL ACH TRANSACTIONS (IAT)

Banking industry rules require the State, as originator of electronic payments, to identify payments where the entire payment amount

is subsequently transferred to a financial institution outside the United States. The rules are referred to as “International ACH

Transaction (IAT) rules” and are pursuant to requirements of the Office of Foreign Assets Control (OFAC), which is part of the

United States Treasury. The IAT rules do not apply to payments made to you via a State warrant. If an electronic payment is

identified as an IAT transaction, the electronic payment must be sent to your financial institution in a special format. Contact your

Financial Institution to see if IAT rules apply to you.

NOTE: The State of Florida does not send payments electronically to financial institutions outside the United States.

TERMS AND CONDITIONS

We will initiate a pre-notification to your financial institution prior to making payment based on this authorization. The pre-

notification is a zero dollar entry transmitted to your financial institution for the purpose of verifying the accuracy of the account and

transit-routing numbers provided and entered into our system.

An authorized representative of the payee must make any changes to the information provided on this form in writing. Changes to

account information will cause the original authorization to be immediately inactivated and the new account information will be

processed as described above. The authorization will remain in effect until terminated in writing with sufficient notice to the State to

allow adequate time to effect termination. The State will not be responsible for any loss that may arise solely by reason of error,

mistake or fraud regarding information provided on this Direct Deposit Payment Authorization Form.

Payments will be made under this authorization using the Corporate Trade Exchange (CTX) format with addenda records. The

addenda records give remittance information about the payment. You must make arrangements with your bank to receive this

addenda information.

You may view payments made to you on our website at //flair.dbf.state.fl.us/

Please contact us at (850) 413-5517 or e-mail at DirectDeposit@myfloridacfo.com if you have any questions or need assistance.